Volume 167 Number 2
We thank Heinrich Schettler, MD, for referral of patient 1. REFERENCES I. Mizejewski GJ. New insights into AFP structure and func-
tion: potential biomedical applications. In: Mizejewski GJ, Porter IH, eds. o-Feroprotein and congenital disorders. New York: Academic Press, 1985:5-34.
Congenital deficiency of AFP
2. Mizejewski GJ, Carter TP, Beblowski DW, Bellisario R. Measurement of serum o-fetoprotein in early infancy: utilization of dried blood specimens. Pediatr Res 1983; 17:4750. 3. Gitlin D. Normal biology of o-feroprotein. Part I. Biology of o-fetoprotein. Ann N Y Acad Sci 1975;259:7-16. Additional references are available from the authors on request.
Successful pregnancy outcomes after amniotic fluid embolism Steven L. Clark, MD Salt Lake City, Utah Two patients who survived cardiorespiratory arrest occurring in association with amniotic fluid embolism syndrome were seen during the subsequent pregnancy. Both had uneventful pregnancies and delivered at term without complications. These are the only case reports of pregnancy after amniotic fluid embolism, and they support a model of amniotic fluid embolism involving chemically abnormal amniotic fluid rather than an unusual sensitivity to normal amniotic fluid. (AM J OaSTET GVNECOL 1992;167:511-2.)
Key word: Amniotic fluid embolism Amniotic fluid embolism syndrome is an often devastating yet incompletely understood condition characterized in its complete form by dyspnea, hypotension, cardiovascular collapse, and coagulopathy. Reported mortality figures approach 80%.1 Because of the clinical features, pregnancy subsequent to documented amniotic fluid embolism syndrome is uncommon and to date has not been reported. We report here the first recorded cases of successful pregnancy after documented amniotic fluid embolism syndrome. Case report Case 1. The patient, a 37-year-old woman, gravida 3, para I, aborta 1, was referred for consultation. Her previous pregnancy 5 years before was complicated in the active phase of the first stage of labor by amniotic fluid embolism syndrome with cardiopulmonary arrest, disseminated intravascular coagulopathy, and cesarean delivery for fetal distress at term. The amniotic fluid From the Department of Obstetrics and Gynecology, University of Utah, and the Intermountain Health Care Perinatal Centers, LDS Hospital. Received for publication January, 2, 1992; revised April 2, 1992; accepted April 16, 1992. Reprint requests: Steven L. Clark, MD, Intermountain Health Care Perinatal Centers, 8th Ave. & C St., Salt Lake City, UT 84143.
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was clear. The patient was one of the study subjects described in a prevoius manuscript detailing the hemodynamic findings of patients with amniotic fluid embolism syndrome." This patient desired an additional pregnancy and wanted information regarding risk of recurrence for amniotic fluid embolism syndrome and the optimal mode of delivery. No information was available with which to counsel the patient with respect to these questions, because pregnancy after amniotic fluid embolism syndrome had not been previously reported. The patient subsequently conceived, carried the pregnancy to term, and at her request underwent elective repeat cesarean delivery. Mother and infant did well without any clinical or laboratory evidence of recurrent amniotic fluid embolism syndrome. Case 2. The patient, a 25-year-old woman, gravida 2, para 1, was referred for care at 35 weeks of gestation after relocating from another area. She had undergone primary cesarean section while she was under spinal anesthesia before labor for breech presentation 2 years previously. As the abdomen was being closed, sudden cardiorespiratory arrest occurred with subsequent disseminated intravascular coagulation and adult respiratory distress syndrome. Squamous cells and fetal hair were recovered from her sputum. She was successfully resuscitated. The patient desired a trial of labor. She entered the
511
August 1992 Am J Obstet Gynecol
Clark
hospital in spo ntaneous labor at 39 weeks and underwent ox ytocin augmentation for dysfun ctional latentph ase contractions. Labor pro gressed rapidly and she underwent an outlet forcep s delivery without complications. Her postpartum cou rse was uneventful. Comment
Alth ough more da ta reg ard ing pregn an cy ou tcome subsequent to amniotic fluid embolism synd ro me is desira ble, these cases represent the only information curre ntly available. In th ese two patients amniotic fluid em bolism syndrome did no t recur during either scheduled cesarean delivery or vaginal delivery after oxytocin-augmented labor. Ou r understanding of th e pathophysiologic characteri stics of amniotic fluid embolism synd rome is incomplete. However, in the primate model the infusion of even large amounts of normal au tologous amniotic
fluid is clearl y not pathologic; recently, an abnormal concentration of amniotic fluid leukotrienes has been implicated .' This report su ppo rts the role of a qualitatively abnor mal amniotic fluid , which ma y be different in a subsequent pregnancy, as oppo sed to any unusual maternal sensitivity to amniotic fluid per se in the genesis of this condition. Altho ugh an y conclusions based on two cases mu st be regarded as tenuous, it appears that on a theoretic basis, su pporte d by these two cases, repeat amniotic fluid embolism syndro me is probably unlikely. REFERENCES 1. Clark SL. New concepts of amniotic fluid embolism: a review. Obstet Gynecol Surv 1990;45:360-8. 2. Clark SL, Cotton DB , Gonik B, Greenspoo n J, Phelan JP. Central hemodynam ic alte rations in amniotic fluid emb olism. AMJ OBSTET GYNECOL 1988;158:1124-6.
Hepatotoxicity with the administration of nifedipine for treatment of preterm labor George F. Sawaya, MD, and Patricia A. Robertson, MD San Francisco, Californi a Nifedipine, a calcium channel blocker, is becoming increasingly popular as a tocolytic medication. Previous reports of hepatitis associated with nifedipine in the medical literature have been published. We present the first case reported of a patient with preterm labor treated with nifedipine who had development of a concurrent elevation in serum liver enzyme levels. (AM J OBSTET GYNECOL 1992;167:512-3.)
Key words: Hepatotoxicity, nifed ipin e, preterm labor We report a case in which the patient had preterm labor treated with nifedipine and an elevation in serum liver en zyme levels occur re d. Case report A 25-year-old primigravid white wom an with a 30week twin gestation was admitted to Lon g Hospital of th e University of Califo rn ia Medi cal Center at San Fran ciso for management of preterm labor. Twin pregnan cy was d iagn osed at 8 weeks' gestation aft er ovuFrom the Department of Obstetrics, Gynecology and R eproductive Sciences, University of California, San Francisco M edical Center. R eceived fo r publication March 10 , 1992; accepted Mardi 31, 1992 . R eprint requests: Patricia A. Ro bertson, MD , Department of Obstetrics, Gynecology & Reproducti ve Sciences, Box 0346, A-809, Uni versity of California, San Fran cisco, CA 94 143- 0346 .
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lation induction with clom iph en e citra te. Her prenatal course was complicated by fre quent uterine contractions at 29 weeks, tr eated with ora l terbutaline . Continued contrac tions with cervical cha nge prompted admission to our ho spital for tocolysis with intraveno us magn esium sulfate and subcutan eous terbutaline. On the second hospital da y ind ometh acin was added to he r tocolytic regimen because of difficult y in controlling th e preterrn labor but was discontinu ed 5 days later becau se of oligohydramnios. At that time th e patient was weaned fro m int raven ou s magnesium sulfate to the terbutaline pump. On the eighth hospita l da y, because of increas ing uterine contraction s with the terbutaline pump alone, nifedipine was adde d to the tocolytic re gimen at a dose of 20 mg every 4 hours. Good tocolysis was achieved . Mildly con sistent elevated blood pressure s prompted laboratory tests to rule out preeclamp-
We thank Heinrich Schettler, MD, for referral of patient 1. REFERENCES I. Mizejewski GJ. New insights into AFP structure and func-
tion: potential biomedical applications. In: Mizejewski GJ, Porter IH, eds. o-Feroprotein and congenital disorders. New York: Academic Press, 1985:5-34.
Congenital deficiency of AFP
2. Mizejewski GJ, Carter TP, Beblowski DW, Bellisario R. Measurement of serum o-fetoprotein in early infancy: utilization of dried blood specimens. Pediatr Res 1983; 17:4750. 3. Gitlin D. Normal biology of o-feroprotein. Part I. Biology of o-fetoprotein. Ann N Y Acad Sci 1975;259:7-16. Additional references are available from the authors on request.
Successful pregnancy outcomes after amniotic fluid embolism Steven L. Clark, MD Salt Lake City, Utah Two patients who survived cardiorespiratory arrest occurring in association with amniotic fluid embolism syndrome were seen during the subsequent pregnancy. Both had uneventful pregnancies and delivered at term without complications. These are the only case reports of pregnancy after amniotic fluid embolism, and they support a model of amniotic fluid embolism involving chemically abnormal amniotic fluid rather than an unusual sensitivity to normal amniotic fluid. (AM J OaSTET GVNECOL 1992;167:511-2.)
Key word: Amniotic fluid embolism Amniotic fluid embolism syndrome is an often devastating yet incompletely understood condition characterized in its complete form by dyspnea, hypotension, cardiovascular collapse, and coagulopathy. Reported mortality figures approach 80%.1 Because of the clinical features, pregnancy subsequent to documented amniotic fluid embolism syndrome is uncommon and to date has not been reported. We report here the first recorded cases of successful pregnancy after documented amniotic fluid embolism syndrome. Case report Case 1. The patient, a 37-year-old woman, gravida 3, para I, aborta 1, was referred for consultation. Her previous pregnancy 5 years before was complicated in the active phase of the first stage of labor by amniotic fluid embolism syndrome with cardiopulmonary arrest, disseminated intravascular coagulopathy, and cesarean delivery for fetal distress at term. The amniotic fluid From the Department of Obstetrics and Gynecology, University of Utah, and the Intermountain Health Care Perinatal Centers, LDS Hospital. Received for publication January, 2, 1992; revised April 2, 1992; accepted April 16, 1992. Reprint requests: Steven L. Clark, MD, Intermountain Health Care Perinatal Centers, 8th Ave. & C St., Salt Lake City, UT 84143.
6/1/38692
was clear. The patient was one of the study subjects described in a prevoius manuscript detailing the hemodynamic findings of patients with amniotic fluid embolism syndrome." This patient desired an additional pregnancy and wanted information regarding risk of recurrence for amniotic fluid embolism syndrome and the optimal mode of delivery. No information was available with which to counsel the patient with respect to these questions, because pregnancy after amniotic fluid embolism syndrome had not been previously reported. The patient subsequently conceived, carried the pregnancy to term, and at her request underwent elective repeat cesarean delivery. Mother and infant did well without any clinical or laboratory evidence of recurrent amniotic fluid embolism syndrome. Case 2. The patient, a 25-year-old woman, gravida 2, para 1, was referred for care at 35 weeks of gestation after relocating from another area. She had undergone primary cesarean section while she was under spinal anesthesia before labor for breech presentation 2 years previously. As the abdomen was being closed, sudden cardiorespiratory arrest occurred with subsequent disseminated intravascular coagulation and adult respiratory distress syndrome. Squamous cells and fetal hair were recovered from her sputum. She was successfully resuscitated. The patient desired a trial of labor. She entered the
511
August 1992 Am J Obstet Gynecol
Clark
hospital in spo ntaneous labor at 39 weeks and underwent ox ytocin augmentation for dysfun ctional latentph ase contractions. Labor pro gressed rapidly and she underwent an outlet forcep s delivery without complications. Her postpartum cou rse was uneventful. Comment
Alth ough more da ta reg ard ing pregn an cy ou tcome subsequent to amniotic fluid embolism synd ro me is desira ble, these cases represent the only information curre ntly available. In th ese two patients amniotic fluid em bolism syndrome did no t recur during either scheduled cesarean delivery or vaginal delivery after oxytocin-augmented labor. Ou r understanding of th e pathophysiologic characteri stics of amniotic fluid embolism synd rome is incomplete. However, in the primate model the infusion of even large amounts of normal au tologous amniotic
fluid is clearl y not pathologic; recently, an abnormal concentration of amniotic fluid leukotrienes has been implicated .' This report su ppo rts the role of a qualitatively abnor mal amniotic fluid , which ma y be different in a subsequent pregnancy, as oppo sed to any unusual maternal sensitivity to amniotic fluid per se in the genesis of this condition. Altho ugh an y conclusions based on two cases mu st be regarded as tenuous, it appears that on a theoretic basis, su pporte d by these two cases, repeat amniotic fluid embolism syndro me is probably unlikely. REFERENCES 1. Clark SL. New concepts of amniotic fluid embolism: a review. Obstet Gynecol Surv 1990;45:360-8. 2. Clark SL, Cotton DB , Gonik B, Greenspoo n J, Phelan JP. Central hemodynam ic alte rations in amniotic fluid emb olism. AMJ OBSTET GYNECOL 1988;158:1124-6.
Hepatotoxicity with the administration of nifedipine for treatment of preterm labor George F. Sawaya, MD, and Patricia A. Robertson, MD San Francisco, Californi a Nifedipine, a calcium channel blocker, is becoming increasingly popular as a tocolytic medication. Previous reports of hepatitis associated with nifedipine in the medical literature have been published. We present the first case reported of a patient with preterm labor treated with nifedipine who had development of a concurrent elevation in serum liver enzyme levels. (AM J OBSTET GYNECOL 1992;167:512-3.)
Key words: Hepatotoxicity, nifed ipin e, preterm labor We report a case in which the patient had preterm labor treated with nifedipine and an elevation in serum liver en zyme levels occur re d. Case report A 25-year-old primigravid white wom an with a 30week twin gestation was admitted to Lon g Hospital of th e University of Califo rn ia Medi cal Center at San Fran ciso for management of preterm labor. Twin pregnan cy was d iagn osed at 8 weeks' gestation aft er ovuFrom the Department of Obstetrics, Gynecology and R eproductive Sciences, University of California, San Francisco M edical Center. R eceived fo r publication March 10 , 1992; accepted Mardi 31, 1992 . R eprint requests: Patricia A. Ro bertson, MD , Department of Obstetrics, Gynecology & Reproducti ve Sciences, Box 0346, A-809, Uni versity of California, San Fran cisco, CA 94 143- 0346 .
6/1/38219
512
lation induction with clom iph en e citra te. Her prenatal course was complicated by fre quent uterine contractions at 29 weeks, tr eated with ora l terbutaline . Continued contrac tions with cervical cha nge prompted admission to our ho spital for tocolysis with intraveno us magn esium sulfate and subcutan eous terbutaline. On the second hospital da y ind ometh acin was added to he r tocolytic regimen because of difficult y in controlling th e preterrn labor but was discontinu ed 5 days later becau se of oligohydramnios. At that time th e patient was weaned fro m int raven ou s magnesium sulfate to the terbutaline pump. On the eighth hospita l da y, because of increas ing uterine contraction s with the terbutaline pump alone, nifedipine was adde d to the tocolytic re gimen at a dose of 20 mg every 4 hours. Good tocolysis was achieved . Mildly con sistent elevated blood pressure s prompted laboratory tests to rule out preeclamp-
